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NURSING HIGHER SECONDARY - FIRST YEAR VOLUME - II Untouchability is a sin Untouchability is a crime Untouchability is inhuman TAMILNADU TEXTBOOK CORPORATION College Road, Chennai - 600 006 ©Government of Tamilnadu First Edition-2004 CHAIRPERSON Dr. Sumathi Kumarswami Former Deputy Director of Medical Education (Nursing) & Executive member Indian Nursing Council– New Delhi & Vice President , State Nurses and Mid-wives Council, Tamilnadu Principal- Madras Medical College, Chennai. REVIEWERS Mrs. C. Vijayalakshmi Dr. K. Rajalakshmi Headmistress & DEO South– I/C Principal Presidency Girls Higher Secondary Appolo College of Nursing School, Egmore, Chennai-600 008. Chennai. AUTHORS Mrs. Harrysingh Mrs. V. Kumari Nursing Teacher Institute of Obstetrics and Mary Club Wala Jadhav Girls Gynaecology and Hospital Higher Secondary School For Women and Children Egmore , Chennai-600 008. Egmore, Chennai- 600 010. Mrs . R. Premalatha Mrs. Menaka Viswanathan Institute of Obstetrics and Presidency Girls Higher Secondary Gynaecology and Hospital School Egmore, For Women and Children Chennai- 600 008. Egmore, Chennai-600 010. Mrs. Noornisha Prof. Udayakumar College of Nursing A.J. College of Nursing Madras Medical College Chennai. Chennai– 600 003. Mr. V. Ramachandiran Management Consultant & Educational Trainer Vinayaka Missions Academy Chennai- 600 028. Price: Rs. This book has been prepared by the Directorate of School Education on behalf of the Government of Tamilnadu. This book has been printed on 60 G.S.M paper ii Printed by offset at: THE NURSES PLEDGE I solemnly pledge myself before God and in the presence of this assembly to pass my life in purity and to practice my profession faithfully. I will abstain from what ever is deleterious and mischievous and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession and will hold the confidence in all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty, I will endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care. The modified Hippocratic Oath arranged by Mrs. Lystra E. Gretter and her committee for the Farrand Training School for Nurses, Detroit is called the Florence Nightingale Pledge as a token of esteem for the Founder of Modern Nursing. The pledge is taken by all the nurses who have completed the training program before entering to their practice. iii CONTENTS Page No Unit –9 1 Health Assessment (cid:216) Assessment (cid:216) Techniques (cid:216) Height (cid:216) Weight Temperature (cid:216) Definition (cid:216) Normal body temperature (cid:216) Factors affecting body temperature (cid:216) Principles of body temperature regulation (cid:216) Nursing care of individual with altered body temperature (cid:216) Recording , Reporting procedure Pulse (cid:216) Definition (cid:216) Normal pulse (cid:216) Assessment of pulse-areas (cid:216) Alterations in pulse (cid:216) Reporting and Recording Respiration (cid:216) Definition (cid:216) Normal rate of respiration (cid:216) Factors influencing respiratory rate (cid:216) Assessment of respiratory rate (cid:216) Nursing care of individual with altered respiration (cid:216) Recording, Reporting iv Blood pressure (cid:216) Definition (cid:216) Normal blood pressure (cid:216) Assessment of blood pressure-Recording, Reporting (cid:216) Nursing care of individual with altered blood pressure Level of conscious ness Unit-10 34 Communication (cid:216) Communication silks (cid:216) Process of communication (cid:216) Models of communication (cid:216) Level of communication (cid:216) Characteristics of effective communication (cid:216) Factors affecting communication (cid:216) Nurse patient relationship (communication with patient, family and health team) (cid:216) Recording & Reporting Unit-11 45 First Aid (cid:216) Definition (cid:216) Basic principles and rules of first aid First aid for patients with (cid:216) Wound , hemorrhage, shock (cid:216) Fracture and dislocation (cid:216) Respiratory emergencies, unconsciousness (cid:216) Burns & scalds (cid:216) Foreign bodies: skin, eye, ear, nose, throat and stomach. v (cid:216) Frost bite, effect of heat, cramps, bites and stings (cid:216) Poisoning and drowning (cid:216) Cardio pulmonary resuscitation(CPR) (cid:216) First Aid Equipments, Bandages and Slings (cid:216) Disaster (cid:216) Community Emergencies (cid:216) Handling and Transporting of injured patients Unit-12 102 Health Education (cid:216) Definition. (cid:216) Aims and Objectives of health education. (cid:216) Principles of health education (cid:216) Methods of health education.(individuals, group and mass) (cid:216) A.V.Aids:Types, selection and uses. Suggested Practicals 117 Bibliography 209 vi 9. HEALTH ASSESSMENTS Health assessment is an important component in health care for proper diagnosis and effective treatment. Health assessment includes the following (cid:216) Physical assessment v Head to foot examination v Systemwise examination v Recording height and weight, (cid:216) Mental status examination (cid:216) Laboratory investigation (cid:216) Special investigation Techniques in physical assessment. Techniques in physical assessment are 1. Inspection – It means looking with eyes. It reveals any rash scar, colour, size shape, contour and symmetry of the body parts 2. Palpation - It means feeling using sense of touch. It reveals any swelling, coldness, hotness, stiffness, hardness, smoothness, roughness, pain, vibration, firmness and flaccidity 3. Percussion – It means striking or tapping with fingers. It elicits sounds which indicate whether the underlined tissues are solid or filled with fluid. The sounds may vary a) Resonant: A loud sound over the normal lung tissue b) Tympanic: A drum like sound over the air filled tissues such as gastric air bubble. 1 c) Dull: a medium pitched sound with medium duration without resonance, heard over the solid tissues, such as heart, liver. d) Flat: A pitched sound with short duration without resonance, heard over the complete solid tissues, such as bones. 4. Auscultation – It means listen with stethoscope or placing the ear against the body. It reveals sounds produced within the body and the blood vessels such as heart beat, bowel sounds. 5. Manipulation: It means moving with the body parts. It reveals rigidity, difficulty or discomfort in moving the body parts. 6. Reflex testing: Means automatic response to a given stimulus. It reveals reflex is present, or not present, strength and movements of hands and legs. 7. Olfaction – It means sense of smell (odour). It reveals the nature of disease condition of the patient. Taking height & weight. It is a measurement from head to toe that indicates the state of growth and health. It is measured in feet, inches or centimeters. Purpose 1. To measure accurate height of the patients Equipments 1. Measuring scale attached to the wall 2. A straight object 3. Paper and pencil 4. Newspaper Guidelines 1. Have the patient’s shoes/ slippers removed while taking height to avoid any variations in the reading 2 2. If thick object is placed on the top of the head, at right angle to the scale indicating the reading, note the bottom reading of the object. Procedure 1. Gather the equipments 2. Explain the purpose and the procedure to the patient 3. Wash your hands 4. Tell the patient to remove the slippers or shoes 5. Assist the patient to stand on a lean newspaper kept on the floor. 6. Tell the patient to stand with the buttocks and the back of head against the scale on wall, feet flat, heals together and eyes looking straight ahead. 7. Place the straight object on the top of the head at right angles to the scale on wall, touching the scale calibration. Note the reading where the said object touches the scale 8. Tell the patient to put on slippers. 9. Place the patient in a comfortable position. 10.Replace the equipments. 11.Wash your hands. 3 Fig 9.1 Measurement of height. Recording 1) Record the date and time of the procedure and the height in the nurse’s notes or graphic sheet Taking weight It is the quantitative expression of a body that indicate the state of growth and health It is measured in kilograms, pounds or grams Purposes 1) To obtain accurate weight of the patient 2) To aid in accurate diagnosis of the patient 3) To evaluate patient’s response to treatment Equipments 1) Weighing scale 2) Newspaper 4